Ischaemic heart disease

Serial hsCRP monitoring predicts recurrent events after ACS

Prof Stephen Nicholls

Monitoring high-sensitivity CRP (hsCRP) levels in the weeks following an acute coronary syndrome (ACS) appears useful in identifying the risk of a subsequent major adverse cardiac event or death.

In a secondary analysis of the multinational VISTA-16 trial that involved 4257 ACS patients including some from Australian centres, hsCRP levels were measured at 1, 2, 4, 8 and 16 weeks .

During the 16 week follow up period, all-cause death (HR 1.25; 95% CI, 1.19-1.32; p<0.001), cardiovascular death (HR, 1.26; 95% CI, 1.20- 1.32; p< 0.001), myocardial infarction (HR, 1.16; 95% CI, 1.08-1.25; p<0.001), and other composite end points were significantly higher in patients with longitudinal increases in hsCRP.

Each SD increment in longitudinal hsCRP concentration was associated with a 15% increased risk of MACE, 25% increased risk of all-cause death, and 26% increased risk of cardiovascular death.

“The associations between longitudinal hsCRP levels and adverse outcomes were identified with adjustment for baseline hsCRP level and assigned treatment in the VISTA-16 trial, as well as a history of intensive treatment with statins and other evidence based treatments for ACS,” the study authors  – including Professor Stephen Nicholls of MonashHeart, Victoria – wrote in JAMA Cardiology.

“Although it remains unclear whether CRP level is a marker or a participant in the atherothrombotic process, identification of increasing CRP levels may help determine which patients may benefit from more intensive treatment.”

They noted that high-dose statins could accelerate a decrease in hsCRP levels.

“These decreases in hsCRP levels, in conjunction with lowering of low-density lipoprotein cholesterol levels, have been shown to be associated with reduced risk of death or major cardiovascular events.”

“The present analysis showed that use of antiplatelet agents (clopidogrel, ticlopidine hydrochloride, or prasugrel) was associated with stable or decreasing hsCRP levels.”

And aspirin has been shown to reduce CRP levels in patients such as those with chronic stable angina and acute myocardial infarction, they added.

The study authors said that more needed to be understood about the associations between inflammation, lipid levels and atherosclerosis.

“Further studies will be required to determine whether initial and serial hsCRP measurements can help guide the use of targeted antiinflammatory therapies after ACS to help further reduce residual cardiovascular risk in this vulnerable population.”

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